ALTERNATIVE THERAPIES IN HEALTH AND MEDICINE __A PEER-REVIEWED JOURNAL * MARCH 1999 » VOL. 5, NO. 2 HYPNOSIS TO ACCELERATE HEALING » CONTROL IN MIND-BODY MEDICINE * PATIENT-PHYSICIAN COMMUNICATION »* TIBETAN MEDICAL DIAGNOSIS » TOLERANCE » PRAYER CIRCLE » NCCAM SYMPOSIUM ABSTRACTS > CONVERSATIONS/MICHAEL MURRAYNOY Eliot Tokar practices traditional Asian medicine in New ‘York, NY. From 1983 to 1986 he studied Tibetan medicine as a student of Dr Yeshi Donden. From 1986 to the present he has been a student of Dr Trogawa Rinpoche, and from 1990 to the presenthe has been a student of Dr Shakya Dorje, He is one of the only North Americans to have received such training, Trained in Chinese and Japanese traditionel medi- cine as well, Mr Tokar has lectured extensively on Tibetan medicine and natura! healthcare alternatives. He advises the American Medical Students Association's National Project on ‘Complementary and Alternative Medicine. ‘To make use ofan oncient traditional meal system, we rust fst comprehend the singular concepis and language that system uses io understand and deseite heath and ness. The diagracie procedure is ‘the seo by which a person's medical colton fs inkepreted into the conceptual framework and language of medial sclece. Ths aril pro- vides a description of traditional Tibetan medical diagnosis and explains hw a Tibetan physician perceive and anabyes a presenting i- sass. discusses th spiritual, psychological, and plystcl eapecs ofthe Tibetan medical approach to diagnasis. Addressing hese sues cam help 1s to understand what io walque about this system of alternative med cine ond how it can inform other raodls of medtcal practic. (Altern ‘Ther Health Med. 199955(2)50-58) hen most patients seek a doctor for a med- ical diagnosis, they generally assume that the process will cleatly and directly reveal the truth about their condition. Their assumption is that the diagaostie procedure ‘ill reveal cher ness in much the same way that cutting open an apple bears its core. in most cases, however, nothing could be far- ther from the truth. In exartining the nature of diagnostic procedures, it is worthwhite to recall the Indian tale of the blind men who “pita lain Comercio 0 ai, la Vg, CAZES pere (GA S99112 0 O19) $4837 (aL 51) fo, AS) SSD 20ES ea eRe SEEING TO THE DISTANT MOUNTAIN: DIAGNOSIS IN TIBETAN MEDICINE Eliot Tokar Origioally presented to the Roundtable on Traditional Medicine, oluenbia Presbyterian Hlspital; New York, NY: April 28,1997, Modified for Alternative Therapies in Health and Medicine. ‘encountered an elephant. In this story each man, feeling only ‘one part of the elephant, draws a completely different and. ‘erroneous conclusion about what he holds in his hands. None ‘of them perceives that he is touching an elephant. Instead, Judging from limited experience, each decides thet the part he is experiencing must equal the whole: the leg is chought to be a tree trunk, the tal a rope, the trunk a snake, and so on. Jn medical diagnosis we healthcare practitioners begin with ‘our own biases, which are based on our personal, coltural, and professional worldview, thus forming the basis either for our blindness or our insight. We obtain a limited set of information that is derived from tests and/or other techniques defined by ‘our tradition’s medical science, Through this analysis, which is based on our understanding, experience, and awareness, we attempt to comprehend the truth ofthe condition. ‘Af we are to succeed we must do better than the blind men ‘of the tale. Sy experiencing the trunk, leg, or tusk, we must be able finally to perceive the whole. We must ultimately have the insight and skil to see the entire elephant, However, becaust of the blindness inherent in the prejudices and limitations of any worldview, we will inevitably see a slightly or even a radically different elephant, LEARNING TO SEE In the teachings of Tibetan medicine there is a metaphor that cefers to the stages of development of the disgnosticion, At the first level a student of medicine i likened to a person stand ing on a mountain top who is unable to perceive what is on the top of the opposite peak. At the next level the student can see that something is there. At a higher level the student can per ceive that someone is standing on the opposite peak but he or she stl lacks the ability to perceive anything about that person. At many succeeding levels, mort and rnore can be peresived about this person until, ultimately, a the most advanced degree of ability, the student recognizes precsely who is there. ‘This metaphor describes the evolation of perceptive abil ties in earning Tibetan medical diagnosis. [ts meaning can also apply to the gradual process that practitioners of different med- ‘eal systems mas: undergo to truly perceive what a doctor from 50 ALTERNATIVE THERAPIES, MARCH 1999, VOL. 5, NO. 2 Secing he Dinan Moun DiagpssinTibon Meine‘another seientific worldview sees, Performing a medical diagno- sis requires an understanding of the technique and language of the system within which one is operating. The foundation of diagnostic shill, however, is the development of a capacity of awareness that leads to lear and precise perception. The following article will explain the basic tools and lan- ‘guage of Tibetan diagnosis and begin to clear the mist that stands between the peak of Tibetan medicine and that of other . To begin establishing a complementary ne, there must be @ common language creat- ed through which traditional and allopathic doctors ean effec- tively communicate about their disciplines. Medical traditions ‘are not the sum total of thelr diagnostic or treatment techniquess instead, they are the result of the scientific, cultural, and spisitu- al knowledge that gave zise to those therapeutic applications, To establish a common language of communication, we must begin by seeing clearly. This point is demonstrated in the book Mortal Lessons by the surgeon and Yale professor Richard Selzer, Mp In this book Dr Selec recounts 2 diagnostic session performed by my first teacher, Dr Yeshi Donden. The session was part of @ demonstra tion conducted at an American hospital. Dx Donden was shown 2 patient about whom he was told nothing, Before an audience of skeptical Western physicians, Dr Donden performed the ‘Tibetan pulse diagnosis and urinalyas. To the amazement of his ancdence he was able to accurately diagnose that the patient had ‘@ chronic heart problem. He diagnosed an imbalance in the basic ‘culatory priociple ofthe body as it relates to blood and heart function. This disorder had progressed to a stage in which it affected the patient's preexisting heart ixregularity, which had developed during a specific stage of embryological development. Dr Selzer' recounted the diagnosis in this manner: [Dr Donden) speaks of winds coursing through the body of the woman, currents that break against barriers, eddy- ing. These vortices are in her blood, he says. The lst spend ings of an imperfect heart. Between the chambers of her heart, long, tong before she was born, a wind had come and blown open a deep gate that must never be opened. ‘Through it charge the full waters of her tives as the moun- tain stceam cascades in the springtime, battering, knocking loose the land and flooding her breath, ‘The allopathic diagnosis had been “congenital heart dis- ease,” an “interventcicula septal defect, with resultant heart fail ure." To Dr Selzer, who was used to the worldview, technique, ‘and jargon of his profession, the Tibetan diagnosis seemed semarhably poetic. Dr Selzer described this diagnosis as a largely divine mystical expetience accessible to priests but no: to mere doctors.’ Interest, fascination, and pechaps even respect were engendered, but little understanding between the doctors seemed to develop. In fact, what Dr Donden was doing was not ‘magic. He was doing what was expected of a properly trained ‘Tibetan physicizn,albeitat its highest level. LIKE A RICH MAN WITH ONE CHILD In deseribing bow he worked as a physician, my teacher, Dr “Trogawa Rinpoche,” remarked: “My external activity isthe prac- tice of medicine, and in my inner thoughts I meditare on the Medicine Buddla.” This comment does not simply tll us that x Trogawa is a religious or pious man. Properly understood, this remarks displays the first step in the process and practice of Tibetan medical diagnosis. It is an ongoing practice toward spisi- tual development and its resultant awareness and intention, ‘toward which the physician continually strives. Given the differ ing levels of practice and development that exist among Tibetan doctors, there is no quantitatively prescribed standacd for this aspect of medical practice, Stil, the primary classic principle of ‘Tibetan medical practices that the bedrock of one's approach to diagnosis lies within the doctor's spiritual practice. In describing the Tibetan approach to diagnosis itis vital to understand how the property trained Tibetan doctor sees the world, After allt is always within a doctor's subjective under- standing ofthe nature of the phenomenal world thatthe reative- ly objective work of obtaining a diagnosis occurs. How, then, do Buddhist teachings determine the basis for making a clear diag- nots offliness? Because the histoical Buddha described his role and teach- ing in a fundamentally medical fashion, this connection is very direct. In fact, because the Buddha's teachings were meant to cure suffering, he was known as the “Supreme Physician."* The Buddhas therefore a ditect inspiration for Tibetan doctors, who attempt to emulate this model ofa spiritually realized being who sakes a conscious choice to cure others. ‘To appreciate how a particular medical system approaches diagnosis, one must discover how a doctor trained in that system perceives the patient. It is important to comprehend the doctor's conscious intention. Buddhist teachings delineate Tibetan doc- tors image of themselves and theic patients as wel s the doctor- patient relationship. Buddhism’s central teachings and practices place great emphasis on (1) understanding and diseovering the nature of one's mind, and thereby transcending ego; (2) develop ing a practice of compassion toward all other conscious beings: and @) developing a sense of equanimity. Therefore, forthe doc- tor of Tibetan medicine there (sno psychological or professional dilemma in directly identifying with his or her patient—as there can be, forinstance, in Western medicine. In.a sense, the Tibetan physician intentionally seeks ¢o identify with the patient. I is, important for us as physicians to intimately understand the basic natare of sufering—both the patients and the doctor's— as well as to understand that our relationship to the patient has both a professional and spiritual significance. ‘Through spiztual practice the Tibetan doctor is trained to emulate a highly spicitually evolved person. A direct conne develops between the doctar’s perception of the patient and a Bodhisattva’ perception of all beings. The term “Bodhisattva” literally means “hero of enlightenment.” Bodhisatovas are spti- tual trainees who strive to generate an altruistic mind oflove and compassion." They are basically Buddhas in the making who Seung me Disa Noone Dage in Tibetan eee ALTERNATIVE THERAPIES, MARCH 1999, VOL. 5,NO.2. SIhhave dedicated their pursuit of spiticual awareness to the single goal of bringing about the welfare af all. ‘We can get a glimpse of the professional ethic Dr ‘Trogawa endeavors to practice in an instruction from the Buddhist sage Vimalakirti: 1am ill becouse all sentient beings are i che illness ofall sentient beings were to come to an end, then nty illness would be ended. Why is this so? Because when the Bodhisattva enters into the realm of birth and death forthe sake of beings, he becomes subject to the laws of this realm and thereupon ‘becomes il. fal sentient beings were to be cured oftheir ds- cases, then the Bodhisativa would never be ill again. ‘tis like the rich man who only has one child, When his child becotnes il, his parents become il. [fhe son is cured of disease, s0 also are the parents. It is the same for the Bodhisattva: he loves all beings as if each of them were his child. When afl beings are cured, then the Bodhisattva will becured..! Before seeing thefr ist patient, Tibetan doctors practice an archetypal diagnosis that becomes a basis far all the diagnoses, they will perform throughout life. This diagnosis is visualized in a ‘meditation practice used by traditionally trained Tibetan doctors. In this meditation physicians visualize the “Buddha of Medicine,” seeing all beings before him, with their particular suffering and all ofthe innumerable diseases they may have. The Medicine Budldha feels anguish for them and wishes them free- dom from suffering, Through the power of his realized rind, this Medicine Buddha diagnoses the illnesses as symptomatic of fundamental spiritual disharmony caused by ignorance, This Ignorance is a lack of understanding of the basic nature of realt- ty, 2s understood from the Buddhist perspective. ‘The resultant confusion leads to activities of our body and. mind that directly or indirectly lesd to suffering and illness. Given this diagnosis, the Medicine Buddha understands the temporary. iUusory nature of illness, Pushing through his sense cof anguish, be delves deeper into this and sees that within every atom of every being who appears as suffering, there exists a Medicine Buddha. Be experiences inner joy in the knowledge that despite suffering, there is the potential for boundless hapo}- ness. Having completed his diagnosis, the Medicine Buddha pro- jects a purifying energy from himself to those before him that reveals the inherently healthy state ‘At this point in the meditation, practitioners merge their own selves with the being of the Medicine Buddha and become indistinguishable from him. They then proceed to a state of ‘meditative emptiness derived from the understanding of the Buddhist teachings, In relation to ehis emptiness, all the forms and concepts we occupy in life~including illness—are under stood as ilusory, dream-like, and therefore highly changeable. Thos it follows that iliness is trade worse or better by changes in the mental perception we give it, The Medicine Buddhe's profound diagnostic skills are derived from wisdom based on deep awareness and perception. ‘These qualities, along with his resultant capacity to heal, makes the Medicine Buddha the role model forthe physician of Tibetan. medicine. By visualizing themselves 25 Medicine Buddha, doc- tors of Tibetan medicine pursue an aspiration to develop the ‘same capacity for compassion, awareness, and slilifulness, This process is the root from which diagnostic skill develops. It is established even before the frst patient walks in the door ‘THE ROOT, THE TREE, THE BRANCHES, THE LEAVES, ‘THE FRUIT All medical systems grow from 3 roots: (1) faith and beliof 42) experience and perception, and (3) objectivity and analysis.“ Westem medicine generally claims to need only the third root, excluding the significance of faith and belief and imagining that experience and perception are superseded by an assumption of scientific objectivity and analysis. Fortunately, as the grassroots alternative medicine movernent becomes a prominent force, ‘Western medicine is beginning to grant some significance to these 2 other roots. Examples of this are Larry Dossey/s? and Herbert Benson's! work on the value of futh and belief in treat- _ment, and Oliver Sacks’s' assertion that the subjective experience ‘of the patients a useful too] in diagnosis. Practitioners of Tibetan medicine have always depended on all $ roots to properly per- ceive and analyze an iliness and its cause in the diagnostic setting. By syathesizing knowledge from various medical systems, ‘Tibetans created a systernatic approach to medical science draw {ng from thousands of years of accumulated empirical know!- edge and intuition about the nature of health and illness. Centuries ago, before Buddhism entered Tibet, Tibetans, Like all ancient people, had a significant degree of medical knowledge, According to traditional sources, in che beginning ofthe 4th cen- tury many new ideas regarding medicine began to entec the country. At frst, influences came from India in the form of what Ss now called Ayurvedie medicine, as well as more spiritually and psychologically based systems from Buddhist and other sources. ‘Around the 7th to 8th centuries the Tibetan government began sponsoring conferences at which doctors skilled in the ‘medical systems of China, Persia, India, and Greece presented ‘and debated their ideas regarding health and the treatment ofill- ness. Those with superior abilities in the diagnosis, treatment, and understanding ofiliness were invited to stay and contribute to the country’s medical knowledge base. In the th century ‘this knowledge was codified nto a unique system." ‘To properly perform Tibetan medical diagnosis, a doctor ‘must have an understanding of che theories of THbetan medicine and thetr unique description of the body—its creation, principal energies, fonctions, and processes—as wel as an understanding cof health and the etiology of ness. As with Western medicine, the quantitative aspect of knowledge in medicine most be mde stood and internalized so it can be readily drawn upon in the diagnostic session. Through instruction from a master and ‘through their own practice, Tibetan doctors in training also gain experience with the qualitative understanding and analysis that 52 ALTERNATIVE THERAPIES. MARCH 1999. VOL. 5, NO. 2 ‘cai iain tue aia a did aan:[ essential in Tibetan medicine, This qualitative dimension clearly differentiates Tibetan medicine from the mechanistic vice of Western medicine, Tibetan medicine views the human ‘body as an ecological system, 2 microcosm diectly related to the ‘macrocosm of the natural world. AlLof the material that makes up our universe is based on the qualities of 5 basic elements, which are described in the ancient physics and depicted in Tibetan medicine. Like all tradi tional people, Tibetans lived in direct contaet with the natural environment. They understood through experience and study that natural environmental forces directly correlated with and. Influenced the functioning of the hurnan organism Tibetans defined the qualities ofthe basic forces existing in nature in the theory ofthe 5 elements. These forces are named for their most {identifiable manifestations: Earth, Water, Fire, Wind, and Space. ‘The characteristics (such asa substance’ taste) and therefore the ‘ature of all mater resott from the qualities of these elements Individually orn combination. Earth has qualities of firmness and stability and therefore provides the basis of physical existence and development, ‘Water creates moisture, giving rise to all fluids. Wind creates movesyent and so enables all aspects of circulation and move- ment, Fire creates tansformation, metabolic functions, and activity, Space provides the potential for existence to be creat- ed in the first place. Combinations of these qualities make up the physical aspect of our bodies as well as the body's distiner physiological energies As with any medical system, understanding the various ‘Ameriong ofthe body is important in Tibetan medicine. However, the underlying physiological principles that create and maintain, ‘those functions are of primary importance. Tibetan medicine defines 3 main systems that control all the body's functions. ‘These 3 sysiems ofthe body, ox Npepa in Tibetan, are created at various stages of development in the womb by on intenetion of ourmind’s developmental process andthe 5 physical elements, | ‘The first, Ling (Wind), creates an enormous number of | functions, the best example of which is circulation. Ling gives vise to and regulates the movement of blood, nerve impulses, thoughts in our minds, and food through the digestive tract and eliminative orgons. The mind expressed as attachment, desive, oF a matzralst worldview is manifested during the pre- natal period through the development of the system of Liing. ‘The second, Tripa (Bl), gives rise to and controls such func- tions as metabolism, liver function, and vision, allowing our mind to function with discriminating intellect. The mind expressed at aggression, hatred, or anger Is manifested during the prenatal period theough the development ofthe system of fripa. Finally, Badlén (Phlegm) creates the physical principe by ‘which energy can be used to produce a function, provide our body's Inbrication, break down food atthe inital stages of diges- tion, ereate che wil and faclitate memory. The mind aeignorance or incomprebension is manifested during the prena- tal period through the development ofthe system of Badin Good diagnostic skills in the Tibeten system require both. | ‘an intellectual understanding ofthe genesis and nature of the 3 ‘Nyepa as well as a subjective appreciation of their qualities and functions. Such grounding in the system allows us to avoid a formulaic ase of the theoretical and practical aspects of the diagnostic technique. To take a simplistic or ideologically Jeound approach is a mistake, because it weakens our capacity to diagnase illness properly, especially in cases of complex or chronic illnesses. It also prevents us from seeing where simple solutions—auch as changes in behavior, Lifestyle, or diet—con ‘be most effective. ‘Tes hanmfil to create a significant dichotomy between what ‘we practice in our own life and what we preach in a professional context. It is most beneficial to patients when doctors develop a healthy iestyle consistent with their understanding of medicine, Such 2 personal practice leads toa deaper understanding of how the action of the mind-—canifested in one’s psychological state ot behavior, including dietary habits—is the primary cause of iiness ‘and therefore shouldbe the primary basis of treatment. ‘The practitioner of natural medicine who is ideologically constrained bya purely quantitative approach will often think in a disease-oriented model more appropriate to che Western med- ical system, A clear understanding of and personal experience ‘with the principles ofhealch and illness are necessary to develop the capacity to make a discriminating diagnosis. When the doc- tor achieves this capacity, treatment will be appropriate to the condition. fc will be based on the use of spirieual, behavioral, psychological, and dietary approaches to affect the root cause of the condition. Then, ifitis relevant to the individual case, herbal medicines ot physieal treatments (eg, aeupuncture) can be ‘employed. This procedure allows the doctor and the patient to ‘void verdependence on therapentic techniques or devices. In the 4 primary Tibetan medical texts (Gyud bZht") the structure ofa tree used as a teaching metaphor. Adopting that ‘metaphor here, the roots of Tibetan doctors’ practice consist of their spictual practice, thelr understanding and study of the medical teachings, and their own personal life experience. The trunk ofthe trees the capacity to flly understand the nature of health and illness, The branches and the leaves are the specific details of medical theary and practice, and the fruit is the ability 10 makea good dlagncsis, SPEAKING, TOUCHING, AND LOOKING “Through spiritual practice, incelleeroal training and incltion, the doctor creates the foundation for the practice of diagnosis. The ‘Tibetan medicat diagnosis consists of 3 main phases. The first is the patient interviews the second is the observation of the urine; the third is the taking of the 12 pulses, after which the doctor may ook. atthe slea ofthe eyes and the surface ofthe tongue, and may fel for sensitivity on certain points ofthe bady. (igure J rom a 17h- ‘century woodcut, shows Tibetan doctor taking apse) Pulse reading and urinalysis require years of theoretical study along with direct instruction by a master. Both of these diagnostic practices combine the art and the science of medi- cine. The reading of the 12 pulses is a subtle process that is best ‘Song to the Distant Mountain: Digs in Tein Mtcne ALTERNATIVE THERAPIES, MARCH 1999, VOL S,NO.2 53FIGURE 4 Tibetan doctor taking a pulse (7th-centory woodcut) conducted ifthe patient has not done anything to grossly disturb his or her physical energies. The patient should prepare for the ple reading by avoiding foods and behaviors that are excessive- ly heating or cooling to the body as well as anyehing that dis- turbs the circulation. Behaviors or dietary practices that distort ‘or discolor the urine sample should be avoided as well. For 24 hours before the appointment, patients should take no medication (except prescription pharmaceuticals, which should not be stopped abrupty) red meat, alcohol, bets, cofee ‘of any kind, black fea, or foods that are unusual to their normal diet, They should also abstain from strenuous physical activity and sexual activity. No vitamins should be taken for 2 days prior ‘to the appointment, Hot showers and baths should not be taken ‘on the morning ofthe appointment. Patients are advised not to ingest anything except water on the day of the appointment; ot, if they must eat, to eat light, esy-to-digest foods at least 10% hours peior tothe appointment.” ‘The patient is asked to bring urine sample that should be taken from the second urination after midnight. Although most dloctors ask simply for the first morning's ine, my teachec Dr “Trogawa Rinpoche states that such a sample could have too ‘many influences fiot che food consumed the previous evening, Ifthe patient goes to bed after midnight and/or wakes up during the night to urinate, the first sample taken in the morning upon arising con be used, Otherwise, the person should be seked to Ding in the second sample taken in the mosting. Because ofthe significant effects of temperature on the urine, the patient is asked not wo reftigerate the sample.” ‘When the patient arives, the physician tries ta discover as such as possible about the problem through listening and ‘observation. The fist step in the interview is observation ofthe patient's physical appeacance and manner of speaking. This is ‘mast useful Fone understands the nature ofthe 3 Agia and the classical physical and psychological sypes that can result from a constitutional predominance of one ora particular combination of these energies (Pable 1). The physician inquires about the patient’s current medical condition as well as how the patient feels personally. Ie may be useful vo investigate the patients med- ical history, health relative to the seasons, dietary pattern, or to engege in ¢ more detailed discussion of personel or spititual Issues. Its useful co ask female patlents about thelc gynecologl- cal bealth and history and their experience with childbisth. Each af these items provides « quantity of health information as well 38 a basls for understanding the nature of a patient's condition vib-is the 5 elements and 3 Nyepa ‘The patient's dietary history ean be especially revealing for 2 reasons. First, following behavior, dit is a primary determi- nant of health. Second, there isa great amount in the Tibetan ‘medical literature about the meaning and significence of foods and the 6 tastes (salty, pungent, sour, bitter, astringent, sweet) with respect to the theory of the 5 basic elements. Under standing a person's dietary habits and reactions to different foods can reveal the basis of his or her condition as well as the circumstances leading fo illness (Table 2). ‘Themanner in which these fietoné can result in idness wil be more or less complex depending on the acate or chronic mature of the problem. Allinesses must be seen as individual and based on. 4 patients baekground, There is a widespread notion that allo pathic medicine only addresses symptoms, whereas natural medi- cine only adresses the root cause of ilness. This is incorreet—an exhaustive list of symptoms i eruelal for achieving a proper dig nosis in Tibetan medicine. Ifa practitioner sees 10 different cases of what allopathic medicine would regard as 1 disease, the addi- tional accompanying symptoms (physical and/or prychological will determine the specific diagnosis in terms of Tibetan medi- ine. Once the full range of symptoms in the context of the patient’ history is discovered, the root cause of the illness can begin to be understood. Within the I disease defined by allopath- je medicine, the Tibetan physician might in fact define 10 difer- ent sets of symptoms, 10 different etiologies, and therefore 10 diferent ilnesses. The root cause of the patient's entice complex cof symptornsis ultimately diagnosed and treated (Figure 2). After interviewing che patient, the Tibetan physician ana- Iyzes a urine sample in a white opaque container. They begin by observing the sample's odor. Spesfic odors described in the texts! correlate with specific conditions. It ls afresh sannple, the pres- ‘ence or lack of vapors helps to define the relative heat/excess ox cold/insulficency manifesred inthe condition. The specimen is, then observed to determine whether ithas a watery appearance or shows degrees ofthe calors yellow, brown, red, or white. ‘Next the physician will determine whether the sample has particular characteristics such as a watery appearance or whether a reddish ting appears around the surface of the sam- ple. A blackish hue, for example, indicates specific conditions such a5 the presence of exceptional toxicity n the system. Any’ deposits in the urine ate noted for their specific appearance, location in the sample, and persistence. Numerous types of deposits and their specif pathologie signiftcance are described inthe texts." 54 ALTERNATIVE THERAPIES. MARCH 1999, VOL. 5. NO. 2 ‘Seciagto the Dltant Mountsin: Diagntsiain Tibetan Medicine|‘TABLE 1 Examples ofchacacterstles corresponding to specific consttational types™ Wind nature person Bile natuse person Pllegn ature person Slightly hunched over Thirsty often Often feels cold “Tendenty to be chin Hungry often Fleshy and/or fat body Bluish complerion ood digestive capacity Small bone steueture Excessively talative Red or blonde hair Pale complexion Complains easily Doesn't experience strong hunger ox thirst Crackingoints Can endate sutering ‘Not materaliste ‘Long fe span Short Bie span Can be igidly opinionated, arogant Mateially welhoff Light sleeper strong body odor Sound sleeper Physically soa Madiumlength lifespan Can contol felings of hatred or aggression Likes music and dancing Moderately materialistic Stable temperament Laughs aot Meatiomn-sizd physicelly Does not outwardly betray feelings held internally Quarrelsorne Likes oweet, biter, astringent, and cooling foods Holds grudges ‘Doesn't ike to be dome Physica skill ‘Once made angry is intractable Tikes sweet and sour and hot tastes Hatred Likes, hor, son, astringent, and stirotan foods ‘Moves around eosily Flexible and agit body ‘Tens to havea good physique aod physica! Comfortable at eights beanty Almay angry Large body Sly or sneaky ‘Can be relied on in matters of importance Not disriminating iculty organizing and psi Allected by even trivial events ‘Moves around. loro either diferent places or situations Capable of malciousness The sample is then vigorously stirced with a sic the size, color, placement, amount, and persistence of bubbles are observed. The observation of the bubbles provides valuable infor- imation regarding the nature of the ness, dhe presence of infee- tion, and the localization ofthe illness. The 4 foundational texts of Tibetan medicine, the rGyud bZhi, and their commentaries Sizing othe Dstt Mount: Dagessin Theta Mediine AUTERNATIVE THERAPIES. MARCH 1999, VOL.S,NO.2 55TTABLE 2 Beamples offoods with matures similar to-and having the potential to cause imbalance in the 3 Njepa" Titan foods that can be harm to Ling Hectng foods that canbe hormult Tipe ‘Coolmg foods that can be harm to Bade Coffee urs Pork Strong tea Meat except goa) Goat meat Greco Fh Goat milk products Mint Fatsandeils Potatoes Poor grode soy sauce ‘Spices (encept parses, erin, coriander, Bell peppers Seaugreck, anise) iste vinegar awe tomatoes Spinach, Bockieat Rggplane Maseard Rabbit and hare Cneambers ‘Sheep milk products ule food Cold igus and chilled food Radishes Food burned in cooking or processing Supe Warereress Chips (Cooked food eaten color at room temperature Onion ‘Suge and areal woot Yam Gadie : Goat cheese Tuip Pepper Colac whit, grey) it Salt ute ricetice akes Peanut butter Whiskey avocedo 1 Sake Mango Chosolare Fes Cola Tied food All alcohol beverages Celery Sesame Molasses describe in detail how the diagnostic sign listed above relate to specific imbalances ofthe Nyepa, individually oc in combination. ‘The effects of organic homeostasis are reflected in the patient's pulse, There are 12 distinet pulses at the radial antery af ‘ach wrist The site of pulse taking should be the distance from the fist crease below the wrist on the distal forearm measured down the length ofthe fcr phalanx of the patent's chomnb, The docty’s fingers are placed flat on the patient's west, parallel and spaced ‘with approximately thewidth ofa grain of ie between them, This placement i chosen because ofits relation to the other artris in 56 ALTERNATIVE THERAPIES, MARCH 1999, VOL. 5, NO.2- ‘Ses the sant Mount: Diaguse In etn MedicineDirection of agnostic onalpis Dingnesis of diseae ‘Diagnosis of Utne complex ands rot cause FIGURE 2 Graphic description of diferece between Western (eft) and Tibetan (ight) medical agnosis. ‘Reprinted from Tokar E, Vora A. “A Tibetan Medleal Paspectve an Irsicble Bowel Syndcome: Building a Means of Discourse fo ttngrative ‘Medicine’ (Altern Complement Ther. 9984151347). Used with permission of Mary Ann Liebert, Ine. the body. itis a proper distance from the heart andliver and there- fore does not have too much or too ltl infinencs on circulatory ‘energy ot blood pressure. Blood and the circulatory energy Cit) from all the organs Now through the distal radial actery, providing {information about the patent’ condition. Analogous to the waves that affect the ow ofthe ocean, the energy that Cows along with the blood exercises its effect i ditect relation to the balance or Imbalance ofthe sie 3.Njepathat constitute the body" Specific pressure ts applied by each fioger and each finger is divided in half longitudinally with each side feeling a distinct pulse CTable 3). Pulse taking involves the assessment of the pulse’ width, depth, strength, speed, and response to pressure. In the texts there are detailed deseriptions of all these qualities, and their indication of health, ines, and fampending death. The speed of the patient's pulse is counted relative tothe physician's respiration rate. Consequently, in performing pulse diagnosis, attention tothe breath sas significant 2¢ isin meditation, ‘The pulses are influenced by the seasons, because all physi- cal phenomena reflect their composition in the 5 elements described above. Hach season bas a clear elemental nature that _elates to the nature of the individual argans. As the funetion of cach organ is affected by the seasons, the pulse takes on specific characteristics during different times of the year. Tibetan physi- ans must be aware of those changes when taking the pulse. ‘When tite different pulses are properly understood and coordinated with the other Lnvestigations described above, one cap clearly define the type of illness, its location, its chronicity, its hidden complications, and other meaningful aspects of ita Ringer Rightindex Readingleft am of atlent Right middle Reading eft acm oF vtiont Right ing Reding left am of patient Laftindex: Reading ight armof patient Left eniddle: ending ght armof patient Left ing: Reading right arm of patent ‘TABLES Placement of fingers in Tibetan pole taking. ‘Oper pesition ‘Mile: Heart Female: Lang Spleen ete kidney Male: Lang Female: Heact ight Kidney Lower pesition Male: small intestines Female large intestine Stomach Repeodueive organs ‘Male large intestine Female: smal intestines Gallbladder Usinary bladder Seg we Dita Mons Ogre in been Mes ALTERNATIVE THERAPIES, MARCH 1999, VOL. 5,NO.2 57‘etiology. To further confirn the diagnosis we can look at the color, shape, and coatings of the tongue; the sclera ofthe eye; and the sensitivity of certain pressure points on the body. ‘SEEING TO THE DISTANT MOUNTAIN: ‘With the doctor solidly rooted in the knowledge and practice of the ecologla! and splcimal undecounding of medicine and che ‘patient prepared to clearly reveal the nature of his or her condition, diagnosis in Tibetan medicine becomes an elegimt investigation into theroot causes of ness. The goal of dfagnosis 2s in meditation, is fo gain insightinto the trae nature of particular phenamena, Thisartiele Is notan exhaustive deseripton ofthe techniques of Tibetan medical dlagnoss, Sach descriptions are available from. published translations and summaries of Tibetan medical texts. (Additional readings on Tibetan medicine are recommended ‘below#) Mastery of the dlagnoscic techniques described in these ‘texts requires lifelong study and practice. in this artiele Thave pro- vided an overview and analysis of an approach to investigating il- ness as thas been taught to me over the past 15 yeas. In Dx Trogawa Rinpoche's clinical approach, the physician arrives ot an individualized, complex diagnosis explaining che systemic imbalances thathave manifested a illness. A multilevel therapeutic approach is crested to treat this imbalance (and sig- nificant acute symptoms) to achieve a truly curative effet. As modernism affects Tibetan medicine, chis more elassieal, holistic approach fo Tibetan medicine is at risk of being lost. The econo- ny of ine and commerce can encourage even Tibetan doctors tothink in dinical terms influenced by the hegemony of Western, rmedieal and technological culture. This typeof lincal shorteat- ting can lead, for example, so an excessive emphasis on the use of medicines to cure a more narrowly defined model ofiliness. ‘As healtheare practitioners, it is omr job to properly diag- nose and treat illness a effectively a5 possible. But that process should be an educational experience for bath doctors and patients, Tibetan medicine deseribes a logical structure for ‘understanding a complex matrix of factors resulting in health or ilness. It provides a set of diagnostic tools to find the causes of Jmbalances that result in poor health, Both ofthese functions are ‘based on a centuries-old tradition of contemplation paired with empirical observation, maintained by a loog, unbroken lineage of teachers. Tibetan medicine reminds us what traditional peo- ple know: that illness must be understood on the basis of the inherent relationship between physical health, psychology, behavior, dit, envienment, and our spiritual existence, Acknowledgments aed ty ths Drogo inpc cd Yo Dey for thie race and guess eh ‘sto cay colleague, Shakya Daye 1 ‘ould al if thsk Rennth Sk rn bs apport od onpariaton of the Roundtable on Traditional Medicine at Columbia Prederteran Hospital New ‘York, NY, at which this paper was Gast daivered. 1 ara most gratefal to ‘Awaette Tokar, and Brian Tokar for thei inaluable assistance felt, this woes Final thanks othe Hindoja Foundation andthe Rosenthal CenterFor alteatize/Complerentiry Meisine fr fending he forum at whi bic pat ‘na orgy presented. References See Maen Ht ntti York Sin Seb Te Dr Trgawe Roped In Hs Owx Words Moward Bea, a2. ‘nhuun) Ph lng Dala Beso, hs Shanks; WE 8. ‘Galena Genie of iso Core Roe Ma Shoal O28. Dade YTioan edn unas, Leseer prseled as Amin te fc ‘dhe So al, anes, Mase “Teor Sein in Teta xii Lecture prseed a: New Yn Feta Gander ovens 2.3886 New Yo. Sean Per Gant toe ay on ony ae Gad ae Hew ihe ing ee of Pg nomae oe ‘Basson intr alg Te Par at ay of if Nee Yo, NY St: Suc. Recyeing ol es, fos, Leste pegented a: New Yok Pabc cay: agen 194; Nek NY. ‘eahn A lar of he oe medial en, Tietey Mace Dhar Ihdeerayoftetan Wha Archive: 98812378. {iggecheT. Icvdecion a Tib tan aise, Lore pteated ot Nar York Shanley 190; New Yok NY ‘opal BDM Doaramsa ede Theta Mail nd Aes ete 108 ‘Ritpoche.Pascates Dnzt, Feward ev Chaka om 19. ei Dayna toed be be ‘Thandup Pe tng Foe of Mad. elon, Sab Xhanghar LD. reso Tein Medi Dhara, nd: bray of Tieton ‘ors an nce 158, ‘hee Nt Dane nny i Ws atric Dj May. hn Me! ig tn Bh snag te arp sens aT Medi. nt Pde Yo bees MeN 300. onion. Heath Thogh Bone ned o Fates dhe ac. Wh ‘Soe Le Pato 08, ‘Teetn ede West Anableat bap/Annatbeanmedkinecem. iarayyareeeanigatttil 58 ALTERNATIVE THERAPIES, MARCH 1999, YOL 5, NO. 2 ‘Sting the Dist Noun Dignan tn Me io